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lec ms > RLE REV > Flashcards

RLE REV Flashcards

1
Q

The nurse is instructing a patient who has a drain in a surgical wound. How will the nurse indicate that the wound will heal?
a. Primary intention
b. Secondary intention
c. Tertiary intention
d. Deliberate intention

A

c. Tertiary intention

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2
Q

What technique will the nurse implement to assist the postoperative patient to cough?
a. Support the patient’s back
b. Offer an antitussive
c. Splint the abdomen with a pillow
d. Lean patient against the bedside table

A

c. Splint the abdomen with a pillow

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2
Q

The day following surgery, the nurse notes bloody drainage on the dressing. How will the nurse describe this drainage when documenting?
a. Serosanguineous
b. Sanguineous
c. Serous
d. Purulent

A

b. Sanguineous

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3
Q

What is the advantage of an occlusive dressing?
a. Allows air to the incision
b. Keeps the incision moist
c. Delays epithelialization
d. Does not have to be changed

A

b. Keeps the incision moist

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4
Q

The nurse is providing instruction to a patient regarding home wound irrigation. How far should the patient hold the hand-held showerhead from the wound when irrigating the wound?
a. 2.5 inches
b. 6 inches
c. 12 inches
d. 18 inches

A

c. 12 inches

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4
Q

When removing the dressing on a patient, the nurse discovers that the gauze dressing has adhered to the wound. What intervention should the nurse implement?
a. Call the RN
b. Gently remove the gauze with sterile forceps
c. Cover with occlusive dressing
d. Moisten the dressing with sterile water

A

d. Moisten the dressing with sterile water

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5
Q

The nurse is irrigating a leg wound of a patient on the trauma unit. Where should the nurse direct the flow of the irrigant?
a. From the area of least contamination to the area of most contamination
b. Forcefully into the wound
c. Gently over the skin into the wound
d. From a distance of about 12 inches

A

a. From the area of least contamination to the area of most contamination

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6
Q

The nurse is removing every other staple from a surgical wound, which has been closed with 15 staples. The wound begins to separate after removal of 3 of the 15. What nursing action should be implemented?
a. Remove 7 more alternate staples and securely tape with Steri-Strips
b. Cover with moist dressing and apply a binder
c. Continue to remove staples as ordered because this is an expected outcome
d. Leave the 12 staples in place and record the separation

A

d. Leave the 12 staples in place and record the separation

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7
Q

The Centers for Disease Control and Prevention (CDC) classifies wounds according to the amount of contamination. What is the classification for an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively?
a. Dirty wound
b. Clean-contaminated wound
c. Contaminated wound
d. Clean wound

A

d. Clean wound

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7
Q

Hemostasis begins as soon as the injury occurs and a clot begins to form. What is the substance in the clot that holds the wound together?
a. Fibrin
b. Thrombin
c. Protime
d. Calcium

A

a. Fibrin

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8
Q

The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?
a. Call the RN
b. Cover the bowel with a sterile saline dressing
c. Turn the patient to the side of the evisceration
d. Raise the patient up to a high Fowler position

A

b. Cover the bowel with a sterile saline dressing

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9
Q

The physician has not ordered a dressing change for a draining wound on a patient in an acute care setting. How should the nurse assess the amount of drainage?
a. Weigh the patient to estimate the weight of the saturated dressing
b. Reinforce the dressing
c. Circle and date the outline of the exudate on the dressing
d. Count each dressing as 1 mL of drainage

A

c. Circle and date the outline of the exudate on the dressing

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10
Q

What phase is a wound in when blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain?
a. Healing
b. Inflammatory
c. Reconstruction
d. Maturation

A

b. Inflammatory

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11
Q

The nurse assessing a postoperative patient discovers that the pulse is rapid, blood pressure has decreased, urinary output has decreased, and the dressing is dry. What can the nurse determine is indicated by these findings?
a. Pain shock
b. Dehydration
c. Internal hemorrhage
d. Acute infection

A

c. Internal hemorrhage

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11
Q

What marked advantage does primary intention have over other phases of wound healing?
a. Healing is rapid
b. Healing rarely becomes infected
c. Minimal scarring results
d. Healing is painless

A

c. Minimal scarring results

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12
Q

The nurse is caring for a patient during the first 24 hours following surgery. How often will the nurse assess for bleeding under the dressing?
a. Every 30 minutes
b. Every 60 minutes
c. Every 2 to 4 hours
d. Every 5 to 8 hours

A

c. Every 2 to 4 hours

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12
Q

The nurse is preparing to perform a dressing change on a patient following a total hip replacement. When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change?
a. After the dressing change
b. At least 15 minutes before the dressing change
c. At least 30 minutes before the dressing change
d. At least 1 hour before the dressing change

A

c. At least 30 minutes before the dressing change

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13
Q

The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound. What is the result of this intervention when the dressing is removed?
a. Destruction of tissue
b. Bleeding
c. Mechanical debridement
d. Prevention of infection

A

c. Mechanical debridement

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14
Q

What is the usual length of time before suture removal?
a. 2 to 3 days
b. 4 to 5 days
c. 5 to 6 days
d. 7 to 10 days

A

d. 7 to 10 days

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15
Q

The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain. What is the maximum amount of drainage considered normal?
a. 50 mL
b. 100 mL
c. 200 mL
d. 300 mL

A

d. 300 mL

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16
Q

What is the classification for the Jackson-Pratt drainage removal system?
a. Sterile drainage system
b. Closed drainage system
c. Open drainage system
d. Self-measuring drainage system

A

b. Closed drainage system

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16
Q

The nurse is caring for a patient with a surgical wound. How can the nurse promote healing?
a. Offer fluids every 4 hours
b. Encourage the consumption of large meals
c. Encourage up to 1000 mL of daily fluid intake
d. Encourage the consumption of small frequent meals

A

d. Encourage the consumption of small frequent meals

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17
Q
A
17
Q

The nurse is instructing a patient about the effects of smoking. What accurate information does the nurse provide?
a. Smoking increases the amount of tissue oxygenation.
b. Smoking increases the amount of functional hemoglobin in blood.
c. Smoking may decrease platelet aggregation and cause hypercoagulability.
d. Smoking interferes with normal cellular mechanisms that promote release of oxygen.

A

d. Smoking interferes with normal cellular mechanisms that promote release of oxygen.

18
Q

The nurse assessing a patient’s wound notes a clear watery drainage. How will the nurse most accurately document this finding?
a. Serous drainage
b. Purulent drainage
c. Sanguineous drainage
d. Serosanguineous drainage

A

a. Serous drainage

19
Q

The nurse assessing a patient’s wound notes thick, yellow drainage. How will the nurse most accurately document this finding?
a. Serous drainage
b. Purulent drainage
c. Sanguineous drainage
d. Serosanguineous drainage

A

b. Purulent drainage

20
Q

The nurse assessing a patient’s wound notes pale red watery drainage. How will the nurse most accurately document this finding?
a. Serous drainage
b. Purulent drainage
c.Sanguineous drainage
d. Serosanguineous drainage

A

d. Serosanguineous drainage

20
Q

The nurse assessing a patient’s wound notes bright red drainage. How will the nurse most accurately document this finding?
a. Serous drainage
b. Purulent drainage
c. Sanguineous drainage
d. Serosanguineous drainage

A

c. Sanguineous drainage

21
Q

The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. What does the nurse recognize that this indicates?
a. Cellulitis
b. Dehiscence
c. Evisceration
d. Extravasation

A

b. Dehiscence

22
Q

The nurse is preparing to redress a wound and will secure the dressing using a gauze bandage as ordered by the physician. What is an advantage of gauze bandages?
a. Provision of warmth
b. Applies strong pressure
c. Antibacterial effects
d. Prevents skin maceration

A

d. Prevents skin maceration

23
Q
A
24
Q
A
25
Q

Which are the phases of wound healing? (Select all that apply.)
a. Reconstruction
b. Hemostasis
c. Inflammation
d. Granulation
e. Maturation

A

A. B, C, E

26
Q

Which solution(s) can be used on a wet-to-dry dressing? (Select all that apply.)
a. Normal saline
b. Lactated Ringer
c. Acetic acid
d. Dakin
e. Lysol

A

A, B, C, D, E

27
Q

What are the advantages of a transparent dressing? (Select all that apply.)
a. Adheres to undamaged skin
b. Contains the exudate
c. Reduces wound contamination
d. Serves as a barrier to external bacteria
e. Slows epithelial growth

A

A, B, C, D

28
Q

A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing?

  1. Alginate
  2. Dry Gauze
  3. Hydrocolloid
  4. No dressing indicated.
A
  1. Hydrocolloid
29
Q

Which of the following are primary risk factors for pressure ulcers? Select all that apply.

  1. Low-protein diet
  2. Insomnia
  3. Lengthy surgical procedures
  4. Fever
  5. Sleeping on a waterbed
A

1, 3, 4

30
Q

An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is:

  1. Risk for Impaired Skin Integrity
  2. Impaired Skin Integrity
  3. Impaired Tissue Integrity
  4. Risk for Infection
A
  1. Impaired Skin Integrity
31
Q

Which statement, if made by the client or family member, would indicate the need for further teaching?

  1. If a skin area gets red but then the red goes away after turning, I should report it to the nurse.
  2. Putting foam pads under the heels or other bony areas can help decrease pressure.
  3. If a person cannot turn himself in bed, someone should help them change position q4h.
  4. The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet.
A
  1. If a person cannot turn himself in bed, someone should help them change position q4h.
32
Q

The client at greatest risk for postoperative wound infection is:

  1. A 3-month-old infant postoperative from pyloric stenosis repair
  2. A 78-year-old postoperative from inguinal hernia repair
  3. An 18-year-old drug user postoperative from removal of a bullet in the leg
  4. A 32-year-old diabetic postoperative from an appendectomy
A
  1. An 18-year-old drug user postoperative from removal of a bullet in the leg
33
Q

Why is a client with fever often predisposed to pressure ulcers?

  1. Pain perception is diminished.
  2. Medications given to relieve fever cause edema.
  3. The client may be too weak to change position.
  4. Increased metabolism causes increased oxygen needs that cannot be met.
A
  1. Increased metabolism causes increased oxygen needs that cannot be met.
34
Q

Black wounds are treated with debridement. Which type of debridement is most selective and least damaging?

  1. Debridement with scissors
  2. Debridement with wet to dry dressings
  3. Mechanical debridement
  4. Chemical debridement
A
  1. Chemical debridement
35
Q

A client’s wound is draining thick yellow material. The nurse correctly describes the drainage as:

  1. Sanguineous
  2. Serous-sanguineous
  3. Serous
  4. Purulent
A
  1. Purulent
36
Q

The nurse cares for a client with a wound in the late regeneration phase of tissue repair. The wound may be protected by applying a:

  1. Transparent film
  2. Hydrogel dressing
  3. Collogenase dressing
  4. Wet to dry dressing
A
  1. Transparent film
37
Q

A client has a diabetic stasis ulcer on the lower leg. The nurse uses a hydrocolloid dressing to cover it. The procedure for application includes:

  1. Cleaning the skin and wound with betadine
  2. Removing all traces of residues for the old dressing
  3. Choosing a dressing no more than quarter-inch larger than the wound size
  4. Holding in place for one minute to allow it to adhere
A
  1. Holding in place for one minute to allow it to adhere
38
Q

A client is admitted to the Emergency Department after a motorcycle accident that resulted in the client’s skidding across a cement parking lot. Since the client was wearing shorts, there are large areas on the legs where the skin is ripped off. This wound is best described as:

  1. Abrasion
  2. Unapproximated
  3. Laceration
  4. Eschar
A
  1. Laceration
39
Q

A nurse is caring for patients with a variety of wounds. Which would will most likely heal by primary intention?

  1. Cut in the skin from a kitchen knife
  2. Excoriated perineal area
  3. Abrasion of the skin
  4. Pressure ulcer
A
  1. Cut in the skin from a kitchen knife
40
Q

Which client information collected by the nurse reflects a systemic response to a wound infection?

  1. Hyperthermia
  2. Exudate
  3. Edema
  4. Pain
A
  1. Hyperthermia
41
Q

When working with an older person, you would keep in mind that the older person is most likely to experience which of following changes with aging?

  1. Thinning of the epidermis
  2. Thickening of the epidermis
  3. Oiliness of the skin
  4. Increased elasticity of the skin
A
  1. Thinning of the epidermis
42
Q

You are caring for an assigned client and notice a superficial ulcer on the client’s buttock that appears as a shallow crater involving the epidermis and the dermis. Which of the following stages would you say best describes this break in skin integrity?

  1. Stage I
  2. Stage II
  3. Stage III
  4. Stage IV
A
  1. Stage II
43
Q

When receiving a report at the beginning of your shift, you learn that your assigned client has a surgical incision that is healing by primary intention. You know that your client’s incision is:

  1. Well approximated, with minimal or no drainage.
  2. Going to take a little longer than usual to heal.
  3. Going to have more scarring than most incisions.
  4. Draining some serosanguineous drainage.
A
  1. Well approximated, with minimal or no drainage.
44
Q

A client’s family asks you to explain some keloid scars that the client developed. The best explanation of the keloid scars would be that keloid scars are:

  1. Due to a relatively rare inherited tendency.
  2. Caused by an abnormal amount of collagen being laid down in scar formation.
  3. Most common in pale-skinned people of Northern European ancestry.
  4. Caused by repeated and abrupt early disruption of eschar being formed.
A
  1. Caused by an abnormal amount of collagen being laid down in scar formation.
45
Q

When caring for an obese client 4 to 5 days post-surgery, who has nausea and occasional vomiting and is not keeping fluids down well, which of the following would you be most concerned about?

  1. Post surgical hemorrhage and anemia
  2. Wound dehiscence and evisceration
  3. Impaired skin integrity and decubitus ulcers
  4. Loss of motility and paralytic illeus
A
  1. Wound dehiscence and evisceration
46
Q

You are at the scene of an accident and find the victim has a bleeding lower leg wound. After flushing the wound with water and covering it with a clean dressing, you find the dressing has been saturated with blood. Which of the following would be the best action to take in this case?

  1. Lower the extremity while applying pressure to the wound.
  2. Take off the first dressing and apply another clean or sterile dressing.
  3. Encircle the client’s ankle with your hands and apply pressure.
  4. Reinforce the first layer of dressing with a second layer of dressing.
A
  1. Reinforce the first layer of dressing with a second layer of dressing.
47
Q

A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing?

a) repositions side to side every 2 hours
b) elevates the head of the bed 60 degrees
c) auscultates the lung field every 4 hours
d) encourages deep breathing exercises every 2 hours

A

b) elevates the head of the bed 60 degrees

lec ms (8 decks)

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